Without evidence of benefit, an intervention should not be presumed to be beneficial or safe.

- Rogue Medic

Issues and Challenges Discussed by Medical Directors at Eagles Conference – Part 2

 

Continuing from Part 1, where A.J. Heightman writes that there are several issues that are important to the medical directors attending the Gathering of Eagles. The conference is over. Here are the rest of the issues –
 

Need for exchange of data between hospital and EMS systems;[1]

 

I can find out what happened to my patients much more easily than most people, because I know the unofficial ways to get the information.

That should not be necessary and HIPAA does allow sharing of this information.
 

Active Shooter management, policies and integration issues, particularly in their Police & EMS integration;[1]

 

It isn’t about who is in charge.

It is about having everyone recognize the same person as being in charge and having that person know how to handle the scene. The person should probably be a specialist, rather than cross-trained to do everything with just the appearance of minimum competence.
 


Images credit from Life in the Fast Lane.
 

STEMI transfers – Hospital are demanding valuable ALS resouces to transfer STEMI and stroke patients when, in some cases, BLS units could handle the task;[1]

 

Why were these patients taken to hospitals that need to transfer the STEMI and stroke patients?

If they were transported by paramedics initially, what good is that kind of paramedic during any transport.

I can’t recognize a stroke or a STEMI, but I am here because you think I am someone who understands strokes and STEMIs.

If the problem is that the protocols require transport to the wrong hospitals, change the protocol.
 


 

Intranasal Narcan delivery by police and firefighters (There is a national push for this by responders who arrive on scene before EMS);[1]

 

It is popular?

So was blood-letting.

Being popular does not mean that it is safe, effective, or a good idea.

What about the well documented opioid overdose mimics that paramedics have trouble with – stroke, hypoglycemia, seizures, et cetera?

What are the outcomes for these patients in systems that make naloxone a BLS treatment, or even just an advanced first aid treatment?
 

Consistency in approach to patient refusals;[1]

 

The patient has the capacity to make informed decisions.

EMS is able to provide adequate information for a person to make an informed decision.

EMS is not coercing refusals.

EMS is competently assessing patients and communicating with patients.
 

Use of video laryngoscopes and capturing the data from them for QA review and documentation;[1]

 

Maybe we should find out if video laryngoscopy is the right tool before we make it the standard of care.

EMS loves standards of care. We don’t care how dangerous they are.
 

Limited funds to bring people in for continuing education;[1]

 

More than continuing – expanding education.

Keeping up with original paramedic education is not enough.

What we need to know changes. We need to keep up, with the changes, not with the past.
 

Airway management and monitoring (particularly failure by crews to use waveform capnography) continues to be an issue;[1]

 

The medic did not include waveform capnography tracings with the chart?

There is less than 100% QA/QI/CYA of intubations?

The medical director does not understand waveform capnography, airway management, and/or oversight?

Not using waveform capnography is due to a critical failure of management that has been adopted by paramedics who have a ceremonial understanding of EMS – enough to pass a test to get a patch, but not enough to provide competent care.

Footnotes:

[1] Issues and Challenges Discussed by Medical Directors at Eagles Conference – Editor-in-Chief A.J. Heightman reports from the 2014 Eagle Creek Retreat in Dallas
A.J. Heightman, MPA, EMT-P
Wednesday, February 26, 2014
JEMS
Article

.

If We Are Not Competent With Direct Laryngoscopy, We Should Just Say So – Part II

ResearchBlogging.org
 

Continuing from Part I of a paper that could, at best, be described as a convenience sample, since a quarter of patients were excluded from randomization because of attending physician bias.

What were the authors assuming when comparing GVL (GlideScope Video Laryngoscope) with DL (Direct Laryngoscopy) for intubation?
 

Intuitively, devices such as the indirect video laryngoscope should improve intubation performance. As such, this study tested the hypothesis that achieving better visualization during the intubation with the GlideScope Video Laryngoscope would result in a better airway management performance as measured by shorter intubation times.[1]

 

The authors also intuitively assume that shorter intubation times mean better airway management. This suggests that speed is the most important factor in airway management.
 


Image credit.
 

They are probably still preaching the myth of the Golden Hour at Shock Trauma.

Is speed more important than quality?
 

There is an excellent assessment of intubation attempt in this paper.
 

Confirmation of intubation attempt duration and success was identified using closed-circuit video.[1]

 

We should not be relying on self-reported intubation success, unless we aren’t interested in a study of fiction. We do not accurately report intubation success, so an objective measurement of success is essential. This should be applied to EMS, as well.
 

The failed intubation rate was less than 0.5%, but the participants had already excluded over a quarter of the patients, so how impressive is a half a percent failure on 3/4 of patients?

What is the success rate for all patients?
 

For all of the statistics regarding study measures, a p < 0.05 was chosen as the threshold for determining significance.[1]

 

Secondary outcome measures are free shots at finding something “significant,” so they should be required to achieve a higher standard than the 1 in 20 p value of < 0.05.[2]

 

To account for any potential bias from patients not enrolled owing to attending discretion, comparison analysis was performed between the eligible, enrolled patients and the eligible, nonenrolled patients. The data demonstrates that all groups were proportionally similar in their demographics, injury mechanism, ISS, and arrival vital signs (data not shown).[1]

 

And, according to Dr. Newman in the SMART EM podcast, the Mallampati scores of the excluded patients were similar to those of the included patients.
 

Used alone, the Mallampati tests have limited accuracy for predicting the difficult airway and thus are not useful screening tests.[3]

 

We conclude that the prognostic value of the modified Mallampati score was worse than that estimated by previous meta-analyses. Our assessment shows that the modified Mallampati score is inadequate as a stand-alone test of a difficult laryngoscopy or tracheal intubation, but it may well be a part of a multivariate model for the prediction of a difficult tracheal intubation.[4]

 

Do the demographics, injury mechanism, ISS, and arrival vital signs increase the ability of the Mallapati to predicting difficult intubation?
 


Image credit.
 

How do we know that the difficulty was similar between included patients and excluded patients?

Similar Mallampati scores.

How useful are Mallampati scores at predicting difficulty of intubation?
 

The pooled estimates demonstrated that only 35% of the patients, who underwent tracheal intubation with difficulties, were correctly identified with a modified Mallampati test.[4]

 

Does the Mallampati score work well for predicting difficulty of intubation with a video laryngoscope?
 

The clinical use of videolaryngoscopes may change the accuracy of predictors of difficult tracheal intubation and require a different definition of difficult tracheal intubation.[4]

 

The Mallampati score does not appear to be of much use in comparing the excluded patients from the included patients, but that is what the authors use to assure us that the patients are similar.

Mallampati scores compare one aspect of visibility, but how important is visibility for intubation?

To be continued in Part III.

Footnotes:

[1] Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial.
Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, Scalea TM.
J Trauma Acute Care Surg. 2013 Aug;75(2):212-9. doi: 10.1097/TA.0b013e318293103d.
PMID: 23823612 [PubMed – in process]

[2] Do multiple outcome measures require p-value adjustment?
Feise RJ.
BMC Med Res Methodol. 2002 Jun 17;2:8. Review.
PMID: 12069695 [PubMed – indexed for MEDLINE]

Free Full Text from BioMed Central.
 

Standard scientific practice, which is entirely arbitrary, commonly establishes a cutoff point to distinguish statistical significance from non-significance at 0.05. By definition, this means that one test in 20 will appear to be significant when it is really coincidental. When more than one test is used, the chance of finding at least one test statistically significant due to chance and incorrectly declaring a difference increases. When 10 statistically independent tests are performed, the chance of at least one test being significant is no longer 0.05, but 0.40.

 

[3] A systematic review (meta-analysis) of the accuracy of the Mallampati tests to predict the difficult airway.
Lee A, Fan LT, Gin T, Karmakar MK, Ngan Kee WD.
Anesth Analg. 2006 Jun;102(6):1867-78.
PMID: 16717341 [PubMed – indexed for MEDLINE]

[4] Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177 088 patients.
Lundstrøm LH, Vester-Andersen M, Møller AM, Charuluxananan S, L’hermite J, Wetterslev J; Danish Anaesthesia Database.
Br J Anaesth. 2011 Nov;107(5):659-67. doi: 10.1093/bja/aer292. Epub 2011 Sep 26.
PMID: 21948956 [PubMed – indexed for MEDLINE]

Free Full Text from Oxford Journals.

Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, & Scalea TM (2013). Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial. The journal of trauma and acute care surgery, 75 (2), 212-9 PMID: 23823612

Lee A, Fan LT, Gin T, Karmakar MK, & Ngan Kee WD (2006). A systematic review (meta-analysis) of the accuracy of the Mallampati tests to predict the difficult airway. Anesthesia and analgesia, 102 (6), 1867-78 PMID: 16717341

Lundstrøm LH, Vester-Andersen M, Møller AM, Charuluxananan S, L’hermite J, Wetterslev J, & Danish Anaesthesia Database (2011). Poor prognostic value of the modified Mallampati score: a meta-analysis involving 177 088 patients. British journal of anaesthesia, 107 (5), 659-67 PMID: 21948956

.

Comment on If We Are Not Competent With Direct Laryngoscopy, We Should Just Say So – Part I

 

In the comments to If We Are Not Competent With Direct Laryngoscopy, We Should Just Say So – Part I, TexasMedicJMB writes the following –
 

I look at the approach of what works for the person performing the intubation is best.

 

No.

What is best for the patient is what is best.

Research to find out what is best for the patient is important.
 

The goal isn’t to satisfy keeping a low-tech approach, the goal is to maximize patient care.

 

That is why we need research.

We can’t just assume that we know what is best without valid evidence. If we are honest about doing what is best for our patients and if we are to behave ethically, we need to find out what is best for our patients.
 

If a difficult airway is encountered and the decision to use a Bougie (flex-tube introducer) is made does this qualify as witchcraft?

 

That depends.

What do I mean by witchcraft?

By witchcraft, I mean treatments that are based on superstition, wishful thinking, and/or anecdote, rather than valid evidence.

Is the decision to use a bougie based on valid evidence?

If not, then the decision may qualify as witchcraft, as I use the term.
 


 

However, you entirely missed the point of my criticism of the opposition to learning by these anesthesiologists.

These witches anesthesiologists refused to participate in research designed to answer a question that has not yet been answered and may affect patient survival.
 

If an anesthesiologist opts to use a Mac 0 on a pediatric pt rather than a text-book suggested Miller 0 is this witchcraft?

 

The textbook recommendation appears to be witchcraft, but feel free to provide valid evidence to support either opinion.
 

If the doctor opts to use VGL because the pt is perceived difficult due to morbid obesity, known CA tumor, etc. why is this witchcraft?
I call it prudent judgement.

 

Is there valid evidence that the GVL (GlideScope Video Laryngoscope) improves outcomes?

If not, then what you describe is not prudent judgement, but mere wishful thinking and therefore witchcraft, as I use the term.
 

From the article at http://www.ncbi.nlm.nih.gov/pubmed/22042705: Compared to direct laryngoscopy, Glidescope(®) video-laryngoscopy is associated with improved glottic visualization, particularly in patients with potential or simulated difficult airway.

 

That is great for someone selling video laryngoscopes

These are only surrogate endpoints, which do not matter.

Surrogate endpoints are just hypothesis generators for studies that will determine if the video laryngoscope actually improves outcomes that matter.

Surrogate endpoints are excellent for self-deception.

Where is the evidence of improved outcomes that matter?
 

From http://ccforum.com/content/17/5/R237: In the medical ICU, video laryngoscopy resulted in higher first attempt and ultimate intubation success rates and improved grade of laryngoscopic view while reducing the esophageal intubation rate compared to direct laryngoscopy.

 

Where is the evidence of improved outcomes that matter?

According to the paper I am writing about,[1] video laryngoscopy resulted in longer intubation attempts and dramatically more hypoxia.

Are we curing the disease, but killing the patient?

Blood-letting also improved surrogate endpoints, while it increased the likelihood of death for patients treated with blood-letting.
 

Physicians observed of old, and continued to observe for many centuries, the following facts concerning blood-letting.

1. It gave relief to pain. . . . .

2. It diminished swelling. . . . .

3. It diminished local redness or congestion. . . . .

4. For a short time after bleeding, either local or general, abnormal heat was sensibly diminished.

5. After bleeding, spasms ceased, . . . .

6. If the blood could be made to run, patients were roused up suddenly from the apparent death of coma. (This was puzzling to those who regarded spasm and paralysis as opposite states; but it showed the catholic applicability of the remedy.)

7. Natural (wrongly termed ” accidental”) hacmorrhages were observed sometimes to end disease. . . . .

8. . . . venesection would cause hamorrhages to cease.[2]

 

I am sorry that your child died, but we consider surrogate endpoints to be more important than the lives of our patients.
 

This paper could have helped to answer that question, but a bunch of anesthesiologists witches decided that they just know and they don’t care about reality or outcomes. In other words, surrogate endpoints are more important than the lives of their patients.
 

As you point out, the article you linked just leaves the sub-group in question at “discretion, unspecified”.

 


 

As Dr. David Newman stated in the podcast,[3] he contacted the corresponding author and was told that all of the attending physician discretion, unspecified patients were because there are some anesthesiologists who refuse to use anything other than a video laryngoscope.

In other words, their patient care depends on prejudice – as does witchcraft.
 

Is the discretion the witchcraft and psychics? Maybe. Is it likely these pt’s were indeed difficult airways the physician felt more comfortable using VGL?

 

Again, according to Dr. Newman, some anesthesiologists insisted on intubating all of their patients with video laryngoscopes, regardless of difficulty. They consider themselves too smart to learn, so they refused to participate.
 

Is the physician truly practicing witchcraft because he chose to perform a procedure known to lower time to intubation, improve first-pass success, etc?

 

Does lowering intubation time improve outcomes?

If video laryngoscopes shorten intubation time, then why did it take longer to intubate patients with the video laryngoscopes?

Valid research could help answer that.
 

Would it have been better if he’d have ignored the VGL device and made several attempts at DL to pass the ETT?

 

Why do you assume that would be the outcome?

Do you have any valid evidence?

One thing this paper does make clear is that there is no good reason to assume that use of video laryngoscopes improve outcomes.
 

The usage of VGL doesn’t appear to be a tool of witchcraft. This is evolution of medicine.

 

You appear to be defending the preventable deaths of patients in order to promote the continuing expansion of witchcraft in medicine.

We do not know what is best, but the anesthesiologists are defending their opinions and protecting their opinions from evidence that may contradict those opinions.

That is witchcraft superstitious nonsense.

Footnotes:

[1] Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial.
Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, Scalea TM.
J Trauma Acute Care Surg. 2013 Aug;75(2):212-9. doi: 10.1097/TA.0b013e318293103d.
PMID: 23823612 [PubMed – in process]

[2] Blood-Letting
Br Med J.
1871 March 18; 1(533): 283–291.
PMCID: PMC2260507

[3] SMART Literature Update
SMART EM podcast
Friday, October 11, 2013
Dr. David Newman and Dr. Ashley Shreves
From about 45:45 to 1:11:00 in the podcast is on this paper.
Podcast page.

.

If We Are Not Competent With Direct Laryngoscopy, We Should Just Say So – Part I

ResearchBlogging.org
 

This study starts out looking good, but there is a huge problem with the design.

If the person intubating felt that he needed to use the video laryngoscope to get the tube, then the patient was not randomize into the study.

How was this paper accepted for publication with such an obviously violation of research methodology?

Did the authors at least track the violations of ethics, so that some analysis of all patients could be attempted?

Maybe this is not really GVL (GlideScope Video Laryngoscope) vs. DL (Direct Laryngoscopy), but a comparison of intubation of the not-so-difficult airway with GVL vs. DL.

What is not-so-difficult? Whatever did not get the doctor to cry, I could not possibly manage that airway safely with a regular laryngoscope!

833 patients would have been randomized, but the person in charge of the airway cried uncle in 210 (just over 25%) of these cases.
 


Image credit.[1]
 

Has airway management really deteriorated to the point where doctors do not feel competent managing 25% of airways without an electronic toy because they are superstitious and believe the toy has magical powers?
 


 

Maybe.

A study could be set up with some sort of objective criteria for excluding the most difficult airways and still be valid, but how do we objectively assess the need for an electric rabbit’s foot?

Did the doctors read their horoscopes and determine that it was a bad day and they needed to use all of their voodoo powers that day?

Did the doctors consult with psychics?

We do not know, because the criteria for superstition are not explained.

This is just a reminder that medicine, and perhaps especially trauma medicine, is still a very superstitious field. It wasn’t that long ago that these patients would have been treated with blood-letting to get rid of the bad humors that prevent healing. Humorous medicine.

Dr. David Newman and Dr. Ashley Shreves describe this in a SMART EM podcast.[2] Dr. Newman corresponded with one of the authors and states that some of the anesthesiologists at Shock Trauma are biased in favor of the video laryngoscope and refuse to use anything else. Were the 210 patients excluded just because some attending anesthesiologists are too biased to learn what works and those anesthesiologists were just throwing a tantrum for all of their patients?

The mythology of I know it works because I’ve seen it work.[3]

Are 25% of the attending anesthesiologists at Shock Trauma too biased to learn?[4]

Or have we improved to the point where only 25% of attending physicians in a specialty are to biased to learn?

To be continued in Part II.

Footnotes:

Image credit for witch’s hat.

[1] Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial.
Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, Scalea TM.
J Trauma Acute Care Surg. 2013 Aug;75(2):212-9. doi: 10.1097/TA.0b013e318293103d.
PMID: 23823612 [PubMed – in process]

[2] SMART Literature Update
SMART EM podcast
Friday, October 11, 2013
Dr. David Newman and Dr. Ashley Shreves
From about 45:45 to 1:11:00 in the podcast is on this paper.
Podcast page.

[3] I’ve Seen It Work and Other Lies
Tue, 21 Jun 2011
Rogue Medic
Article

[4] It would be the anesthesiologists managing just over 25% of the intubations, rather than 25% of the anesthesiologists, but no information is provided to clarify how many anesthesiologists that would be.

The result of the bias affects just over 25% of patients.

Yeatts DJ, Dutton RP, Hu PF, Chang YW, Brown CH, Chen H, Grissom TE, Kufera JA, & Scalea TM (2013). Effect of video laryngoscopy on trauma patient survival: a randomized controlled trial. The journal of trauma and acute care surgery, 75 (2), 212-9 PMID: 23823612

.

Factors associated with failed intubation attempts in the ED – Difficult Airway

ResearchBlogging.org
 

As with any procedure, each attempt at intubation increases the chance of harm to the patient.

What can we do to minimize the possibility of making more than one attempt at intubation?
 

The aim of this study was to identify factors associated with successful second and third attempts in adults following a failed first intubation attempt to support an effective rescue attempts strategy in the ED.[1]

 

Click on images to make them larger.
 

The success rate for each attempt was about 80% for the first, second, and third attempts. Several factors seem to have influenced that success rate, but the most important appears to have been the presence of a difficult airway.
 

The 6 academic EDs were equipped with core airway devices and drugs, one or more extraglottic devices, one or more video laryngoscopes and fiberscopes, RSI drugs, and one or more cricothyrotomy sets or kits.[1]

 

All intubations were supervised by a senior physician, so they should be well prepared for difficult airways.
 

A difficult airway was defined as a case in which the first intubator anticipated the difficult airway considering 3 dimensions of difficulty: difficult laryngoscopy and intubation, difficult bag-mask ventilation, and difficult cricothyrotomy.[1]

 

In the discussion, the authors suggest that they may have come up with higher rates of difficult airways for the first intubation attempt due to using three criteria to identify difficult airways.

This should not suggest that their conclusions about difficult airways are weakened. The opposite is more. They were less likely to miss a difficult airway. Difficult bag-mask ventilation may not be predictive of a difficult airway, but the increasing proportion of difficult airways among the failed intubations suggests that these airways were difficult.
 


 

Perhaps if we view the difficult airways as a proportion of the successes and failures of each intubation attempt, it will make things more clear.
 


 

Only 26.3% of first intubation attempt failures, but 36.5% of second intubation attempt failures, and increasing dramatically to 64% of third intubation attempt failures.

This does raise the question of why 36% of third intubation attempt failures were not considered difficult intubations?

Were they only going by the initial assessment of difficult intubation?

Shouldn’t we be reevaluating as we get further information as the Reverend Thomas Bayes advises?[2]

Footnotes:

[1] Factors associated with successful second and third intubation attempts in the ED.
Kim JH, Kim YM, Choi HJ, Je SM, Kim E; on behalf of the Korean Emergency Airway Management Registry (KEAMR) Investigators.
Am J Emerg Med. 2013 Jul 29. doi:pii: S0735-6757(13)00395-1. 10.1016/j.ajem.2013.06.018. [Epub ahead of print]
PMID: 23906622 [PubMed – as supplied by publisher]

[2] Bayesian inference
Wikipedia
Article

Kim JH, Kim YM, Choi HJ, Je SM, Kim E, & on behalf of the Korean Emergency Airway Management Registry (KEAMR) Investigators (2013). Factors associated with successful second and third intubation attempts in the ED. The American journal of emergency medicine PMID: 23906622

.

What Laryngoscope Blade Do You Use? – Why?


 

Which laryngoscope blade is your favorite?

Does length matter?

Does strength matter?[1]

Dr. Minh LeCong asks this at his blog PHARM – PreHospital And Retrieval Medicine.

There is also a video that provides some information on blade size.
 

[youtube]gYxwhEmYb9w[/youtube]
 

One of the problems with the video is the hand position. The laryngoscope should be held so that the hand is touching the blade. I prefer to have my ring finger touching the blade.

The higher the hand is on the handle, the more likely that the handle is used like a slot machine handle, as I demonstrate below.
 

[youtube]r2tQE61IGzo[/youtube]
 

The way to intubate is to position the patient before even picking up the laryngoscope (and premedicating with oxygen and whatever else is appropriate), then only advance the blade as far as necessary for each step of laryngoscopy.

1. Find the tongue.

Yay! That was easy.

2. Advance the laryngoscope and find the epiglottis.

Not as easy, but just more important.

3. Lift up (either in the valecula or under the epiglottis – it does not matter) and find the arytenoid structures. The vocal cords are above the arytenoid structures, so there is no need to lift up any farther.

4. Advance the bougie/tube over the arytenoid structures without touching anything else. It isn’t about cleanliness. The biggest problem I see people have when trying to intubate is that they do not avoid everything else in the mouth and end up trying to force the tube.

Force should never be used in the airway.

We should not arm wrestle with the airway. We will lose.

Go ahead and try to force this airway. I double dog dare you.
 


Image credit. It is all in the positioning.
 

The goal of airway management is to out-think the airway, not to out-muscle the airway.

As with martial arts, strength improves with repetition due to the development of muscle memory, even if there is no increase in strength. Technique requires a lot of repetition.

If you have not intubated a mannequin over a thousand times, you are still learning technique. We can always learn more.

We tend to be satisfied with very little practice, as if the patient owes it to us to inhale the tube.

This is ridiculous, but I find that for almost every class I have taught, I intubated the mannequin more times than everyone else in the class combined. I offer to let students practice as much as they want. I offer to help or to leave them alone.

Why is intubation of the airway of another human being so unimportant to so many of us?

Why do so many of us pretend that we are good at intubation?
 

Intubation shouldn’t be that hard, but research repeatedly shows us that we become airway stupid when things do not go as planned – and we are often the cause of the problems with our plan. Even if our plan is not just having the patient inhale the tube.
 

Most adults can be intubated with a #2 Mac or a #2 Miller. A longer blade is only necessary for a patient with an unusually long mandible.

Understanding of the airway is more important than blade size. Any spatula will do.

A blade should be relatively wide and flat. A tongue depressor would work well, but this would require some practice to manipulate the tongue with a tongue depressor. A tongue depressor is wider and flatter than a Miller, so a tongue depressor is better designed than a Miller to lift the tongue out of the way.

Why isn’t the Miller blade designed to lift the tongue out of the way? Was Miller in cahoots with the trial lawyers?

I prefer a Grandview, but a lower profile Grandview would be nice.
 

[youtube]xURQ12UAcMg[/youtube]
 

This is from Dr. Richard Levitan’s Airway Cam series.

Dr. Levitan is one of the top airway doctors in emergency medicine. Notice how low his hand is on the blade. It may be someone else manipulating the laryngoscope, but probably someone who has received input from Dr. Levitan on intubation technique.

The wrist is lower than the blade. This makes it more difficult to pull back on the blade and easier to lift up with the blade.

Intubation is not about a long blade, or a strong arm, or pulling back, but many people attempt to intubate using all three of these mistakes.

Intubation is about thinking, preparation, positioning, technique, and lifting the tongue up.

Footnotes:

[1] PHARM Poll : Blade choice in direct laryngoscopy – does length or strength matter?
by rfdsdoc
on May 2, 2013
PHARM – PreHospital And Retrieval Medicine
Article

.

How Accurate are We at Rapid Sequence Intubation for Pediatric Emergency Patients – Part I

ResearchBlogging.org

Which patients cause most of us the most anxiety?

Kids.

Which patients do most of us least want to injure?

Kids.

What skill do we tend to brag about as if we are much better than our actual success rates?

IVs, 12 lead ECG interpretation, and even driving are up there for EMS, but the biggest exaggeration is probably for intubation.

Combine all of these and move to the ED (Emergency Department) and the skill most inaccurately represented as positive may be pediatric intubation.

Is this because we unintentionally remember only some of our errors in managing pediatric airways?

An article in the current Annals of Emergency Medicine suggests that the errors reported are much lower than the actual number of errors during pediatric RSI (Rapid Sequence Intubation/Induction).

These studies likely underreport the frequency of both first-attempt failure and adverse effects because of voluntary self-reporting or the limitations of chart review. Our clinical experience and quality assurance efforts suggested that failed first attempts and adverse effects occur more commonly than reported for pediatric emergency patients undergoing RSI.[1]

Are they right?

The goal of our study was to accurately and thoroughly describe the process, success, and safety of RSI for patients in a busy pediatric ED. Using video review, we specifically sought to determine the frequencies of first-attempt success and adverse effects for patients undergoing RSI in a pediatric ED.[1]

The video does not lie – at least it is less motivated to lie.

Video review was the primary source for all study data; if a data point was unavailable or unclear from the video, it was obtained from the medical record or consensus review. If not recorded in the medical record, the data element was considered missing for that subject.[1]

None of the doctors reviewed their own patients.

In this ED, critically ill or injured patients are managed in one of 4 resuscitation bays by a designated team, which includes emergency physician and nurse team leaders, a pediatric or emergency medicine resident, several bedside nurses, and a respiratory therapist. The physician team leader is either board certified in pediatric emergency medicine or a second- or third-year fellow in pediatric emergency medicine. For critically injured patients, the team also includes a general surgery resident, a surgical fellow or attending surgeon, and providers from anesthesiology and critical care. During the study period, no standard protocol for the practice of RSI was in place and video-assisted laryngoscopy was not routinely performed.[1]

These should be the calmest, coolest, most collected of the people intubating children, so the tendency to unintentionally under-report errors may be least with these doctors.

In other words, we should expect that other hospitals, and especially EMS, should be much more stressed out and much less accurate in their reporting of errors.

The primary outcome was success of intubation with the first attempt, which included all insertions of the laryngoscope blade with the intent to intubate, even when there was no insertion of the tube, but they do not explain how they determined intent.

If I place the laryngoscope in the airway, how does anyone know what my intent is?

If I am holding the tube in my hand, this may just be a reasonable way to be prepared for an unexpectedly easy intubation, even though I had not been intending to place the tube. This is much more likely to be the case when the patient has not received RSI medications. The best reason for taking a look without the intent of intubating is before the RSI drugs are given, because the main reason to look first is to see if there is something that would make RSI especially dangerous in this patient.

If I take a look in the airway and decide that intubation with RSI is not the best way to manage this patient’s airway, is that a failed attempt. According to this study – only if I have pushed RSI drugs.

However, suppose that I have pushed RSI drugs and notice something I had not noticed earlier. If I take a look after pushing the RSI drugs, but place an extraglottic airway, that is a failed attempt. If I never use the laryngoscope, that is not a failed attempt, but it is also not an intubation. This does not appear to have been the case for any patients, but it is a good idea to be prepared to use Rapid Sequence Airway.[2],[3]

Our secondary outcome was the occurrence of adverse effects, measured as the number of patients with video evidence of 1 or more adverse effects during RSI.2, 16 [1]

Unfortunately, they had to rely on statements about the adverse events, except for the obvious (such as CPR), in order to recognize adverse events, because they did not have continuous records of the information on the monitors.

If the patient has an adverse event, but nobody notices or it is corrected without comment, the adverse event did not happen, at least as far as this study is concerned. RSI-related adverse events are unlikely to resolve spontaneously, so that should not affect the outcome, but a nurse, or doctor, could easily correct something and not state it out loud, especially if the people working together are accustomed to communicating without stating the obvious.

Here is the way they dealt with these limitations –

We attempted to identify the following adverse effects with only video review: nonairway intubation, inadequate paralysis (vocalization, biting, or general movement at the first attempt), vomiting, and endotracheal tube obstruction. The following adverse effects were identified with the aid of the medical record: mainstem bronchial intubation (confirmatory chest radiograph), aspiration (foreign material visualized in the airway or a combination of vomiting and new infiltrate on chest radiograph), pneumomediastinum, pneumothorax, and dental/oral injury.[1]

In Part II I will discuss the results. Some are good. Some are not so good.

Footnotes:

[1] Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review.
Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, Mittiga MR.
Ann Emerg Med. 2012 Sep;60(3):251-9. Epub 2012 Mar 15.
PMID: 22424653 [PubMed – in process]

Free Full Text from Annals of Emergency Medicine.

There will probably be a podcast by David H. Newman, MD, and Ashley E. Shreves, MD. covering this paper, but the current issue podcasts usually do not get posted until a few weeks after the current issue. Annals Podcast page.

[2] Rapid Sequence Airway (RSA)–a novel approach to prehospital airway management.
Braude D, Richards M.
Prehosp Emerg Care. 2007 Apr-Jun;11(2):250-2.
PMID: 17454819 [PubMed – indexed for MEDLINE]

[3] Rapid sequence airway vs rapid sequence intubation in a simulated trauma airway by flight crew.
Southard A, Braude D, Crandall C.
Resuscitation. 2010 May;81(5):576-8. Epub 2010 Feb 18.
PMID: 20171002 [PubMed – indexed for MEDLINE]

Average time to secure the airway was 145 s shorter in the RSA group (95% CI: 100.4-189.7). Lowest oxygen saturation was 4.8% higher (95% CI: 2.8-6.8) in the RSA group. During RSI, FC placed a back-up airway 47% of the time.

Kerrey BT, Rinderknecht AS, Geis GL, Nigrovic LE, & Mittiga MR (2012). Rapid sequence intubation for pediatric emergency patients: higher frequency of failed attempts and adverse effects found by video review. Annals of emergency medicine, 60 (3), 251-9 PMID: 22424653

.

Blogs and Podcasts to Keep Up With Research

What are my favorite places for research information?

The site that has probably helped me find more of these than any other is Life in the Fast Lane. Every Friday, they have a literature review –

Each version of The LITFL Review begins with The Most Fair Dinkum Ripper Beaut Of The Week, which appears to be an expression of antipodean delight. They even have a page of their favorite podcasts.

Funtabulously Frivolous Friday Five 051 is a literature-themed example of their semi-medical punctuated education series. They ask a question, then you can click on the answer. The page does not need to reload, which is handy on a cell phone or a slow computer, it is just revealed.

A new feature is Friday Feynman Inspiration 001.

Mill Hill Ave Command is a newer blog (only been around since September), but one that provides a lot of useful information and discusses research. One post is Pain control – Recent controversies and research.

The Poison Review is what it says. A review of new toxicology research. A great way to learn about what we can do and what we should not do. One recent and very relevant example is Case report: seizures after smoking a synthetic cannabinoid product.

EMS Compare and the pages linked to it, provide an overview of the state of resuscitation in the US. Your organization can make claims about how good you are, but this the research on the topic. There is also an EMS Wiki for adding information. An excellent job of organizing information.

Capnography for Paramedics provides a lot of research and links on capnography – one of the more important EMS skills.

EMS Evidence Based Protocols – provides research on the many different treatments we provide in EMS and the quality of the research supporting these treatments.

Dr. Bryan Bledsoe provides some explanation of what is right, or what is not right, about things we do in EMS. For example – PDF of Searching for the Evidence Behind EMS.

Gary Schwitzer’s HealthNewsReview Blog is a review of the many ways the media misrepresent research. How the media provide bad information – one example two examples in one – Surrogate outcomes, progression-free survival: important issues for journalists & consumers to grasp. It is also important for anyone reading research to know the difference between a surrogate endpoint (only good for creating hypotheses and for evaluating treatments of rare diseases) and survival (as if there is any excuse for settling for anything other than being able to enjoy survival)

Resus.Me provides reviews of new emergency medicine research. A recent post is Listen over the neck when inflating ETT cuff.

A couple of news sites provide some research and both of these have regular articles on airway Dr. Darren Braude and Dr. Richard Levitan.

Emergency Medicine News

Emergency Physicians Monthly

Journal Watch provides weekly summaries of new research articles. They have one free summary in each category each week. You can register for free, or for a yearly charge, you can get access to all of them. They have over a dozen different specialty categories, including emergency medicine and airway articles by Dr. Ron Walls. Emergency Medicine Top Stories of 2011.

The NNT – The red/yellow/green light rating is probably the clearest presentation of what works, based on the best research available. Here are a couple of examples – ACLS Medications for Cardiac Arrest and Opiates During Abdominal Pain Evaluation

The daily concise research reviews from EM Literature of Note are my favorites. Each post is a few paragraphs of what we need to know about a new emergency medicine research paper. A recent example is Why Aren’t You Using Nitrous Yet?. A sample of the kind of common sense Dr. Radecki brings to analysis of research is –

they don’t specifically record whether they are able to successfully complete the intended procedure with this method – however, one would imagine, if it didn’t work the first 7,000 times, they wouldn’t have kept doing it…

The highlighting is mine.

Then there are the podcasts –

Annals of Emergency Medicine Podcast provides a nice review of the research papers in each month’s Annals of Emergency Medicine. From December – Relationship Between Pain Severity and Outcomes in Patients Presenting With Potential Acute Coronary Syndromes2 1/2 minute podcast segment on just this paperFree Full Text of Article with link to PDF Download.

Smart EM – This, the Annals podcast, and The NNT are all Dr. David Newman, who appears to be even busier than me. A great podcast (a couple of hours long, but definitely worth it) is SMART Cardiac Arrest: Pharmacotherapy.

EMCrit – With his first podcast on aggressively treating patients with high-dose nitrates (and ignoring furosemide), I was hooked. I have been trying to get people to understand this for over a decade. Dr. Weingart explains it in less than 10 minutes. EMCrit Podcast 1-Sympathetic Crashing Acute Pulmonary Edema.

ERCast Dr. Rob Orman’s podcast. Pediatric Fever.

Pedi-U is a great pediatric podcast. Kyle David Bates talks with Dr. Peter Antevy and Dr. Lou Romig and an occasional guest about things emergent in pediatrics. A great episode continuing on the topic of fever – Facts About Fever: Information You “Mythed”.

Keeping Up with Emergency Medicine is now a video with data from the research presented on slides in the video. video of Article of the Week – Droperidol for AgitationPDF Download of the article summary.

Standing Orders Podcast recently started up again after a hiatus with Episode 8: Surviving The Next Shift. What does it take to make it through a shift safely and go home every time? Dr. Chris Russi does a research review – Research Review Episode 2: “Fluid Administration in Traumatic Injury Patients” We are working on having me do a regular segment on the podcast.

EMS Research Podcast a podcast that is on hiatus. We hope to start it up again in 2012. In Fentanyl Study: EMS Research Episode 9 we review a well done study of fentanyl in trauma patients, including hypotensive trauma patients. The patients were just as likely to increase their blood pressure and no longer be hypotensive as they were to become hypotensive. Clearly, there is no good reason to prevent treatment of hypotensive trauma patients with fentanyl.

My favorite of the podcasts is Free Emergency Medicine Talks. These are collected by Dr. Joe Lex and include a lot of talks from recent emergency medicine conferences. Sometimes the audio is not great, but the information is excellent. One example is 2011 Literature Update Cardiology – Amal Mattu, an excellent update on the cardiology research that matters for EMS and emergency medicine.

If you know of other research sources, please let me know and I will add them.

.